Combined deployment technique
The entire combined procedure was performed in an electrophysiology
laboratory, under sterile conditions and with the patient undergoing
conscious sedation or local anesthesia. The first part of the S-ICD
device system placement procedure was performed following the
two-incision technique as first reported by Knops et
al. 7. Device pocket was created inter-muscularly,
carefully separating the anterior surface of the serratus anterior and
the posterior surface of the latissimus dorsi muscle.
Before device deployment, an AAE was retrieved. To allow fitting of the
S-ICD device, the envelope was processed as follows: first, the envelope
was dipped in a sterile bath of 0.9% saline. Then, using a surgical
scissor, both lateral edges of the envelope were cut, to increase the
envelope width span. As per manufacturer indication, the envelope was
flipped inside out. The S-ICD device was then inserted into the wet,
flipped, opened envelope. Through manual compression, envelope adhesion
to the S-ICD was maximized. Three surgical knots, two anchoring the
envelope to itself and one attached to the catheter port of the S-ICD
device, were put in place, to guarantee envelope stability and fixation.
Device was then placed in the inter-muscular pocket and standard
techniques to suture the pocket and the incision site were used. The
steps used for envelope preparation and deployment are shown inFigure 2 . At the end of the procedure, fluoroscopy was used to
assess final system positioning. As per manufacturer indication, a
2-views chest radiography was obtained in the first post-operative day.
All procedures were performed in high-volume centers by expert
proceduralists (M.B., C.L.G., G.B.F.), with an extensive experience with
the S-ICD system placement as well as with AAE.